Treatment of gonorrhea.
Women with suspected STD infection should be screened for pregnancy, as some medications may not be appropriate for women who are pregnant.
Screening and treatment of sexual partners is important in preventing reinfection and complications.
Prophylactic treatment for gonococcal infection in newborns includes silver nitrate, erythromycin, ciprofloxacin, gentamicin or erythromycin eye drops.
1. Inpatient or outpatient treatment.
Once the diagnosis is confirmed or is likely, the need for inpatient treatment should be considered.
For male gonorrhea patients, it is usually outpatient treatment, and if disseminated gonorrhea or gonorrheal arthritis occurs, hospitalization is required.
For women with gonorrhea, the choice between inpatient or outpatient treatment is more difficult because of the high risk of complications in women with gonorrhea. Given the poor compliance, high chance of reinfection, and difficulty of follow-up, some physicians recommend that female patients should be admitted to the hospital whenever complications, such as pelvic inflammatory disease, occur, especially in the adolescent population.
Many institutions are trying to find indicators of pelvic exams (such as pelvic inflammatory disease scores) to help find those with a high likelihood of complications for hospitalization.
To prevent the risk of future infertility, most physicians take aggressive treatment measures, especially if the patient is very young or uneducated.
Patients with corneal gonococcal infections also require hospitalization to give intravenous antibiotic therapy. Once the infection is controlled and the corneal infection improves, the patient can be discharged from the hospital.
2. Surgical treatment.
Septic arthritis should be aspirated to help establish a diagnosis and reduce inflammatory exudate. Open drainage is not advocated unless it occurs in the hip area in children. For women with pelvic inflammatory disease, most experts recommend removal of the IUD.
3. Drug treatment options.
Because of resistance to oral cephalosporins, the United States currently recommends a combination of 2 drugs, ceftriaxone + azithromycin, for the treatment of gonorrhea. The combination therapy should be given on the same day. In addition, patients infected with gonorrhea may have co-infection with chlamydia, so treatment of gonorrhea should be combined with treatment of chlamydia, which further supports the combination of ceftriaxone + azithromycin.
(1) The first-line 2-drug combination regimen for uncomplicated urogenital tract, anorectal, and pharyngeal streptococcal infections is as follows.
Ceftriaxone 250 mg single dose intramuscularly, plus, Azithromycin 1 g single dose orally Azithromycin 1 g PO single dose data showed that cefixime 400 mg single dose oral treatment could not maintain high bactericidal concentrations. In addition, the sensitivity of cefixime was decreasing between 2009 and 2010. As a result, the CDC changed its guidelines to exclude oral cephalosporins from the first-line treatment regimen.
Because of gonococcal multidrug resistance, in 2015, the CDC treatment recommendations are as follows.
Gonorrhea at any site may be treated with ceftriaxone 250 mg single dose intramuscularly combined with azithromycin 1 g single dose orally.
If ceftriaxone is not available, cefixime 400 mg single dose orally in combination with azithromycin 1 g single dose orally may be given.
Alternative regimen: If cephalosporin allergy is present, a different combination regimen can be given, such as Gemifioxacin 320mg single dose orally, combined with Azithromycin 2g single dose orally. Or gentamicin 240mg intramuscularly, combined with azithromycin 2g orally.
Another alternative for cephalosporin allergy is daikonomycin 2g intramuscularly. Daikonomycin may be more expensive and is less commonly used in the market today.
In case of azithromycin allergy, doxycycline treatment (100 mg orally twice daily for 7 days) can be given in combination with ceftriaxone or cefixime.
After 1 week of treatment the patient should return to review for cure. For patients who fail treatment, a drug sensitivity test is recommended, along with reporting to the local public health system.
Azithromycin given as a single agent is no longer recommended because it may lead to gonococcal resistance to macrolides, and there have been reports of treatment failure found with azithromycin. Gonococci in the United States are not susceptible to penicillin, tetracycline, or erythromycin, and therefore these drugs are not recommended for the treatment of gonococcal infections.
Screening and future treatment options.
2 new antibiotic regimens can successfully treat gonococcal infections, including gentamicin intravenously combined with azithromycin orally, or gimifioxacin orally combined with azithromycin orally. Although the results of the study found that the above 2 treatment regimens were effective, these drugs can cause serious gastrointestinal side effects. However, these 2 regimens can be considered in cases where ceftriaxone cannot be used.
Gentamicin combined with azithromycin is 100% effective in treatment, and Gemifioxacin combined with azithromycin is 99.5% effective. Both of these 2 regimens have a 100% cure rate for gonococcal infections of the pharynx and rectum.
Despite the high efficacy, they can cause gastrointestinal side effects. Twenty-eight percent of patients treated with gentamicin combined with azithromycin had nausea, 19% had diarrhea, and 7% had abdominal discomfort/pain or vomiting. Of patients treated with Gemifioxacin in combination with azithromycin, 37% had nausea, 23% had diarrhea, and 11% had abdominal discomfort/pain.
(2) Gonococcal arthritis.
Ceftriaxone 1 g intravenous/muscular injection once daily combined with azithromycin 1 g single dose orally is recommended. Intravenous/myeloablative therapy needs to be continued until 1-2 days after symptoms improve.
Alternative treatment regimens include cefotaxime or cefixime 1g IV once every 8 hours combined with azithromycin 1g single dose orally.
(3) Gonococcal conjunctivitis.
Adults are recommended ceftriaxone 1g single dose intramuscularly, combined with azithromycin 1g single dose orally, and saline lavage. Topical topical antibiotics can easily be considered as well. Some physicians recommend intravenous antibiotic therapy for 3 days (e.g. ceftriaxone 1g intravenously, every 12-24 hours) if corneal involvement cannot be ruled out or because of swollen eyelids or begging conjunctival edema.
(4) Gonococcal pelvic inflammatory disease.
All treatment regimens for pelvic inflammatory disease should be effective against gonococci and chlamydia, as a negative cervical screen does not exclude upstream infection by these microorganisms.
The recommended regimen is ceftriaxone 2 g intramuscularly combined with doxycycline 100 mg twice daily for 14 days, with or without concomitant metronidazole 500 mg orally twice daily for 14 days.
Other treatments are equally effective and require consideration of the severity of pelvic inflammatory disease and the presence of tubo-ovarian abscesses.
(5) Gonococcal epididymitis.
Recommended treatment includes ceftriaxone 250 mg single dose intramuscularly combined with doxycycline 100 mg orally twice daily. For 10 consecutive days.
(6) Disseminated gonorrhea.
Ceftriaxone 1g intramuscularly/intranasally every 24 hours in combination with azithromycin 1g orally as a single dose.
Alternative regimen-Cefotaxime 1g every 8 hours or ceftizoxime 1g every 8 hours in combination with azithromycin 1g single dose orally.
Ceftriaxone IV therapy is recommended to be maintained for at least 24-48 hours until clinical improvement before switching to inotropic therapy.
The total duration of treatment with the combination of intravenous and intravenous cephalosporin antibiotics should be 7 days.
(7) Gonococcal meningitis and endocarditis.
Hospitalization and treatment as recommended by the infection specialist.
Consultation.
Consider consultation in the following cases.
Gynecologists – pregnant women with severe pelvic inflammatory disease and infectious diseases.
Pediatrician – any child with an STI.
Ophthalmologists – every patient with gonorrheal conjunctivitis, as the disease can progress rapidly and lead to permanent blindness.
Infectious disease specialists – especially in cases of disseminated streptococcal infections or complicated diseases.
In patients involved in rape or abuse, specialists should be sought to help with interviews and specimen collection. It is medico-legally important to document the condition carefully. In case of pregnancy abuse, the child’s guardian should be notified.
4. Monitoring.
Patients with disseminated gonococcal infection or pelvic inflammatory disease treated in the outpatient setting must have reduced follow-up within 24 hours.
Patients with unremitting or recurrent symptoms should be followed up and gonococcal cultures and drug sensitivity tests should be performed with or without treatment.
Immediate follow-up examinations are not recommended for patients with uncomplicated gonorrhea, whether treated with first-line or alternative regimens. For patients with gonococcal pharyngitis treated with daikonomycin, efficacy needs to be assessed and should be less than 60% effective rate.
CDC recommends a review after 3 months of treatment, which is different from when it is available for examination.
5. Prevention.
Prevention of gonococcal infection requires education, physical or chemical prophylaxis, early diagnosis and treatment. Condoms are partially protective, and treatment with effective antibiotics before or shortly after exposure can end the infection.
Interventions also include notification of sexual partners. Isolated patients notify sexual partners and seek medical help.
The American College of Obstetricians and Gynecologists guidelines recommend sexual partner drug-dispensing for STIs such as chlamydia and gonorrhea, as follows.
Sexual partner drug-dispensing treatment prevents reinfection.
Partner counseling to test for HIV and other STD pathogens.
Suspecting abuse or a safety concern is to prohibit partners from bringing medication for treatment. Assess potential abuse risk prior to treatment.
Sexual partner drug-dispensing treatment medications and criteria are based on CDC, national and/or local guidelines.
6. Screening.
Screening is recommended for women at risk of infection because of the presence of asymptomatic gonorrhea as follows
Have a prior history of gonococcal infection.
Have other STDs.
Have a new or multiple sexual partners.
Not using condoms consistently.
Commercial sex and drug use.
Areas with a high prevalence of gonorrhea.
Because gonococcal infection without symptoms is rare in men, routine screening for men is recommended unless there is a relatively high risk of infection.
7. Neonatal prophylaxis.
All children born to mothers with untreated gonococcal infections should be treated prophylactically with ceftriaxone (25-50 mg/kg IV/MI, up to 125 mg). All newborns should use 1% silver nitrate eye drops once each or 0.5% erythromycin eye ointment once in each eye to prevent ophthalmia neonatorum.